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��, County • <br /> ?,� pIl Industry Services Division c C T� I C DANE <br /> ' v; 1400 E.Washington Ave., P.O. ox C j \/ C anitary Permit Number(to be filled in by Co.) <br /> ?ob=t Madison,WI 53707-7162 SEP 1 4 2015 <br /> l-3-ZdI�- 4Dz9y <br /> Sanitary Permit Application Public Health MDC State Transaction Number <br /> PP Environmental Health <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(lxm),Stats. <br /> 1. Application Information-Please Print All Information BARTON RD. <br /> Property Owner's Name 0.7€4LLC SuNrvY R l D L-E 1---1-(---- Parcel# <br /> JEFF GRUNDAHL (4 C cess 0,4 Jc (NEo) 4-0606-271-8600-0 <br /> Property Owner's Mailing Address <br /> Property Location <br /> 10964 COUNTY HWY A ,.---Ncv 1/4, NE %, Section 27 <br /> City, State, Zip Code Phone Number <br /> HOLLANDALE,WI 53544 608 576-7850 T 6 N,R 6 E <br /> II.Type of Building(check all that apply) f Lot# 1 Subdivision Name <br /> for 2 Family Dwelling-Number of Bedrooms ( 4 Block# <br /> ❑Public/Commercial-Describe Use CSM Number ❑City of <br /> ❑State Owned-Describe Use 12585 i/ ❑Village of <br /> I own of BLUE MOUNDS <br /> HI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. [71 System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration New Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ['Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain): <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Pr.:.•to is` System Elevation <br /> 600 0.6 17 1000 `/ i ( 103.7' <br /> VI.Tank Info Capacity in Total #of Manufa'•.. <br /> S� <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks8 U ti <br /> B = 2 z cn <br /> a U iii H al is 3 c <br /> Septic or Holding Tank 1250 1250 1 DALMARAY X <br /> Dosing Chamber 750 750 1 DALMARAY X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) lum is Si MP/MPRS Number Business Phone Number <br /> SCOTT LOVELACE 226-852 (608)465-3314 <br /> Plumber's Address(Street,City,Sta , ip Code) <br /> LOVELACE PUMP COMPANY, INC., 9914 COUNTY M, ARGYLE, WI 53504 '\ <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee /.- Date Issued suing Ag ' tgna <br /> (\ ❑Owner Given Reason for Denial $ /Z y6 -- -I S i.11& ' <br /> IX.Conditions of Approval/Reasons for Disapproval 77 <br /> .Attach to complete rt a sys ar+ds 't to the County only on paper not less than 8 1/2 x 11 inches in size <br /> SBD-6398(R.08/14) <br /> Q0 , 0 , B C/41„,„. <br /> 1 � <br /> P yt <br />